Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Ridge Village during CMS and state inspections, most recent first.
A resident was discharged without receiving the required ABN and NOMNC notifications regarding Medicare/Medicaid coverage and potential liability for non-covered services. Staff interviews confirmed that these notifications were not consistently provided, and the facility lacked a formal policy, relying instead on CMS guidelines.
A resident with an anxiety disorder received PRN clonazepam multiple times without staff documenting non-pharmacological interventions attempted prior to administration. The care plan lacked details on the use of anti-anxiety medication and interventions, and the facility had no policy or established process for such documentation until a recent system update.
Two residents prescribed psychotropic medications did not have their care plans updated to reflect new medication orders, monitoring for side effects, or non-pharmacological interventions. The MDS coordinator confirmed omissions in care plan documentation for both an antidepressant and an antianxiety medication.
Staff did not complete accurate assessments or provide timely interventions for two residents with complex medical needs. One resident continued to receive compression hose after the order was discontinued, with inconsistent documentation and confusion among staff about current orders. Another resident with cardiac conditions and on anti-coagulant therapy had chronic bruising that was not properly documented or tracked due to omissions in the initial assessment and unclear staff responsibilities.
A resident with a history of falls and cognitive impairment was observed multiple times in bed without required fall mats, despite care plan directives and recent injury. Staff interviews revealed inconsistent awareness and implementation of fall prevention measures, and documentation of interventions was not reliably completed. The DON confirmed the care plan was not followed, contrary to facility policy.
A resident with multiple cardiac and respiratory conditions did not receive oxygen therapy as ordered, with observations showing the oxygen flow rate set below prescribed levels and periods when oxygen was not administered at all. Staff interviews revealed inconsistent practices in monitoring and adjusting oxygen delivery, leading to a failure in providing safe and appropriate respiratory care.
Staff failed to follow infection prevention protocols for two residents: one with an indwelling catheter did not receive care using required EBP, including the use of gowns and proper disinfection after a spill, and another with respiratory symptoms was not promptly placed in appropriate isolation, resulting in continued participation in group activities while symptomatic. Staff interviews revealed inconsistent understanding and application of infection control policies.
The facility was found to have deficiencies in food storage and labeling practices. Open food items, such as planko crumbs, sugar, pancake mix, and taco shells, were undated and uncovered. Additionally, thawing meat was improperly stored above other food items in the refrigerator, contrary to the facility's policy. The Dietary Manager acknowledged these issues, which violate the facility's Food Receiving and Storage policy.
The dietary staff at the facility failed to properly execute the pureed food process for residents requiring a pureed diet. A cook was observed pureeing meals without measuring ingredients or using the correct scoop size, and admitted to not being trained on the process. The VP of Culinary stated that staff should follow specific recipes and use a graph to determine scoop size if changes are made, as per facility policy.
Failure to Provide Required Beneficiary Notifications at Discharge
Penalty
Summary
The facility failed to provide required beneficiary notifications regarding Medicaid/Medicare coverage and potential liability for non-covered services to a resident upon discharge. Specifically, clinical record review showed that a resident who was admitted and later discharged did not receive the Advanced Beneficiary Notification (ABN) or the Notice of Medicare Non-Coverage (NOMNC) as mandated by federal regulations. When surveyors requested documentation, the facility was unable to produce the required notifications for this resident, although notifications for two other residents were provided. Interviews with facility staff revealed that the Social Services Coordinator, who was newly hired, discovered the missing notifications while auditing previous work. She confirmed that the required notifications had not been given to some residents at discharge. The DON acknowledged awareness of the missing notifications but stated that overseeing this process was not within his responsibilities. The facility administrator reported that there was no formal policy on ABN/NOMNC notifications, but that the facility follows CMS guidelines.
Failure to Document Non-Pharmacological Interventions Before PRN Anti-Anxiety Medication
Penalty
Summary
Facility staff failed to document non-pharmacological interventions attempted prior to administering anti-anxiety (AA) medication to a resident diagnosed with anxiety disorder. The resident was admitted with a diagnosis of anxiety disorder and was prescribed clonazepam 0.5 mg every 8 hours as needed. Over the course of two months, the medication was administered multiple times, but the clinical record and Medication Administration Record (MAR) lacked documentation of non-pharmacological interventions attempted before each administration. The resident's care plan did not include information about the use of AA medication or the non-pharmacological interventions used or attempted prior to administration. Interviews with staff revealed that, until recently, there was no process in place for documenting non-pharmacological interventions prior to PRN AA medication administration. The electronic MAR system had only recently been updated to prompt staff to document such interventions, but prior to this update, no documentation was required or completed. Additionally, the Director of Nursing confirmed that the facility did not have a policy regarding psychotropic medication use and non-pharmacological interventions.
Failure to Update Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for two residents who were prescribed psychotropic medications. For one resident, the care plan initiated did not document the use of an antidepressant or provide directives for staff regarding monitoring for medication side effects, despite physician orders indicating the resident was started on Lexapro for depression. The MDS coordinator confirmed that the antidepressant was not added back to the care plan after the resident returned from the hospital and the medication was prescribed. For another resident with diagnoses of anxiety disorder and depression, the care plan was missing information about the use of an antianxiety medication, non-pharmacological interventions attempted prior to administration, and monitoring for side effects or symptoms related to the medication. The resident's order summary showed a PRN order for clonazepam for anxiety, but this was not reflected in the care plan. The MDS coordinator acknowledged that the antianxiety medication was not listed in the care plan at the time of review.
Failure to Complete Accurate Assessments and Provide Timely Interventions for Residents with Edema and Skin Conditions
Penalty
Summary
Staff failed to appropriately complete resident assessments and provide timely interventions for two residents with significant medical needs. For one resident with a history of coronary artery disease, hypertension, heart failure, localized edema, and acute respiratory failure, the care plan did not document the use of compression hose as ordered. Despite a physician's order discontinuing the use of compression hose, staff continued to apply them, and there was confusion among staff regarding whether the resident should be wearing them. Documentation in the electronic health record and medication administration record was inconsistent, with staff unsure about current orders and responsibilities for monitoring and documenting the use of compression hose. For another resident with multiple cardiac diagnoses and long-term use of anti-coagulant therapy, the initial assessment failed to document the presence of purpura or chronic bruising on the forearms and hands. The care plan instructed staff to monitor for bruising due to anti-coagulant use, but there was no ongoing documentation of bruising in the medication administration record or nursing progress notes after the initial mention. Staff interviews revealed a lack of clarity regarding who was responsible for tracking and documenting the bruising, and the initial assessment's omission led to the absence of a tracking task for this condition. Both deficiencies were identified through clinical record review, observations, resident and staff interviews, and policy review. The findings indicate that the facility did not ensure accurate and complete assessments or timely interventions according to physician orders and resident needs, resulting in lapses in care planning, documentation, and monitoring for residents with complex medical conditions.
Failure to Implement Care Planned Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain care planned interventions to prevent and mitigate falls for a resident with a history of falls and significant cognitive impairment. The resident, who had diagnoses including atrial fibrillation, stroke, a displaced fracture of the right femur, and senile degeneration of the brain, was care planned to have fall mats on both sides of the bed, the bed in the lowest position, non-skid footwear, and a clutter-free environment. Despite these documented interventions, multiple direct observations revealed that the resident was in bed without fall mats in place on several occasions. Staff members, including a registered nurse and certified nurse aides, did not consistently recognize or implement the requirement for fall mats, and documentation in the electronic health record was not reliably completed to confirm that interventions were in place. Interviews with staff indicated a lack of awareness or understanding of the resident's care plan requirements, with some staff unaware that fall mats were needed and others confirming that documentation of interventions was expected but not always performed. The Director of Nursing acknowledged that the care plan was not being followed and expressed concern about the potential for harm, especially given the resident's recent femur fracture. Review of facility policy confirmed that the nursing team is responsible for communicating and implementing fall prevention interventions for residents with a history of falls.
Failure to Ensure Safe and Accurate Oxygen Therapy Delivery
Penalty
Summary
The facility failed to ensure safe and accurate delivery of oxygen therapy for a resident with significant cardiac and respiratory diagnoses, including coronary artery disease, heart failure, and acute respiratory failure with hypoxia. The resident's care plan and physician's orders specified continuous oxygen therapy at 2-3 liters via nasal cannula to maintain oxygen saturation above 88%. However, multiple observations revealed that the oxygen concentrator was set below the ordered range, at 1 1/2 and 1 3/4 liters, and at one point, the resident was found without oxygen, with both the concentrator and portable tank turned off and the tubing stored away. The resident had to request staff assistance to have her oxygen reapplied. Staff interviews indicated a lack of clarity and consistency in following the oxygen therapy orders. A CNA reported that she only turns the oxygen on or off and does not adjust the flow rate, while an RN initially believed the oxygen was set correctly but, upon closer inspection, found it was below the ordered rate and adjusted it. These actions and inactions resulted in the resident not receiving oxygen therapy as ordered, constituting a failure to provide safe and appropriate respiratory care.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for residents requiring enhanced barrier precautions (EBP) and droplet/contact precautions. For one resident with obstructive uropathy and an indwelling catheter, staff did not follow EBP guidelines as outlined in the care plan and facility policy. During an observed catheter care procedure, the certified nursing assistant (CNA) wore gloves but did not don a gown as required. Additionally, after urine was spilled on the floor, the CNA cleaned the area with a paper towel instead of using an appropriate disinfectant, contrary to the infection preventionist's expectations and facility policy. Staff interviews revealed inconsistent understanding and application of EBP protocols. One CNA believed EBP was only necessary for residents with certain infections like influenza, COVID, or C. difficile, while another stated she would use a gown and gloves for catheter care if an EBP sign was posted. The infection preventionist clarified that a gown and gloves should always be used for catheter care and that contaminated surfaces must be disinfected with approved wipes, not just wiped with a paper towel. In a separate incident, another resident with respiratory symptoms and a diagnosis of Parainfluenza Type 2 was not placed in transmission-based precautions (TBP) until after returning from the emergency department, despite having symptoms for several days. Staff interviews indicated a lack of clarity regarding when to initiate isolation and which type of precautions to use. The care plan was not updated to reflect the resident's symptoms or need for TBP until after the diagnosis was confirmed, and the resident continued to participate in communal dining while symptomatic.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, as observed during a survey. In the main kitchen, several open food items, including a 25-pound bag of planko crumbs, a 25-pound bag of sugar, two boxes of pancake mix, and packages of hard and soft taco shells, were found undated and uncovered. Additionally, a tray of frozen meat was improperly stored on a middle shelf in the walk-in refrigerator, thawing above a pie, which violates the facility's policy of storing thawing meat separately and on the bottom shelf to prevent cross-contamination. During an interview, the Dietary Manager acknowledged the expectation that dry food should be stored in sealed containers and that open food should be sealed, labeled, and dated. The facility's Food Receiving and Storage policy, revised in October 2018, requires dry foods to be removed from original packaging, labeled, and dated, and mandates that uncooked and raw animal products be stored separately in drip-proof containers below fruits, vegetables, and other ready-to-eat foods. The policy also specifies that opened containers must be dated and sealed or covered during storage.
Deficiency in Pureed Food Preparation Process
Penalty
Summary
The facility's dietary staff failed to properly execute the pureed food process for three residents requiring a pureed diet. During an observation, a cook, identified as Staff A, was seen pureeing chicken fried steak, corn, and strawberry shortcake without measuring the ingredients or using the appropriate scoop size as per the facility's guidelines. Staff A admitted to not being trained on the puree process and was uncertain about the correct scoop size to use for serving the residents. In an interview, Staff B, the VP of Culinary, stated that kitchen staff are expected to follow specific recipes from [NAME] Brothers, which include exact measurements for food, fluids, and thickeners, as well as the correct scoop size for serving. Staff B emphasized that if any changes are made to the recipe, the graph should be used to determine the appropriate scoop size, and the serving staff should be informed of any changes. The facility's policy on Appealing Pureed Foods also documented the need to follow the correct amounts of food as noted in the recipe.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Des Moines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewater, A Wesleylife Community | 0.7 mi | ★★★★★ | 4 | 0 |
| Arbor Springs Of West Des Moines L L C | 0.7 mi | ★★★★★ | 2 | 0 |
| Harmony West Des Moines | 3.3 mi | ★★★★★ | 21 | 0 |
| The Village Of Legacy Pointe Nursing Facility | 3.5 mi | — | 0 | 0 |
| Deerfield Health Care Center | 3.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.